Posted December 01 2017 11:07am
November 2017 - Sault Area Hospital’s Algoma Geriatric Clinic (AGC) offers specialized comprehensive assessment and treatment to medically complex and frail elderly in an outpatient setting. It is designed to maximize the level of independence in the lives of geriatric patients living in the community. Modelled after the Regional North East Specialized Geriatric Services (NESGS) program in Sudbury, the AGC officially opened its doors in 2013.
The clinic is unique because it focuses on providing the elderly with holistic care, including not only the physical/functional needs of the patient, but all aspects of their health - emotional, environmental, social factors and personal safety issues. “Our program focuses on geriatric care, with the primary goal of supporting patients so they can continue to live in their homes,” says Amanda Luther, Patient Care Manager.
The AGC multidisciplinary care team includes a nurse practitioner, social worker, registered nurse, physiotherapist, occupational therapist, clerical support and a team of physicians including a recently recruited geriatrician. “We are pleased to welcome Geriatrician, Dr. Katriina Hopper, to our team. She will join our family physicians in the clinic, Dr. Lorraine Sharp, Dr. Trish Parsons, and Care of the Elderly Physician, Dr. Frank Ianni,” says Luther.
Staff are cross-trained as geriatric assessors, providing timely, comprehensive assessments and management plans for the geriatric population. “Each new patient will receive a comprehensive assessment by a geriatric assessor, followed by a second assessment with a physician.”
During the assessment, an in-depth review of all aspects of health and a “head-to-toe” physical examination is performed for each patient. “This type of assessment is very time intensive and is not conducive to being done in the primary care practitioner’s office,” says Luther. “We are able to spend more time with the patient which allows for opportunities to address multiple co-existing medical problems. We use a holistic approach to care, we look at all medical issues, and we make suggestions regarding care and follow up to ensure treatment has been optimized,” she adds.
Once the assessments are complete, a plan of care will be created and shared with the patient/family, the patient’s primary care physician and the community agencies that are enlisted to support the patient. The team in the AGC also meets regularly for case conferencing. “Our team, along with our community partners, meets regularly to discuss more complex patient cases. We work together to problem-solve and discuss how we can best meet the needs of all our patients.”
One of the programs operated by the AGC is the “Frail to Fit” program which offers geriatric patients who are at risk of falls, exercises and education that will improve balance, strength and coordination. It is led by the AGC physiotherapist and occupational therapist twice a week for groups of eight patients. “This is a 12-week class and then patients are referred to one of the community group programs to continue with a maintenance program,” says Luther. The AGC is currently participating in a research study, led by the clinic’s Dr. Lorraine Sharp. “In this study, if we demonstrate sustained patient improvement after the 12-week program, we may receive funding to continue offering the exercise program in the community.”
Luther says that the clinic also has built a robust outreach program. “We have an outreach program with Collegiate Heights and the Wawa Family Health Team. Our team will go to Collegiate Heights to conduct follow-up appointments for residents who are AGC patients and we hope to expand this service to other retirement homes in the future.” In addition, the AGC has a partnership with the Geriatric Coordinator in Wawa. “Through this partnership and the use of Ontario Telemedicine Network (OTN), these patients no longer have to travel to SAH for ongoing follow-up care.” If deemed appropriate by a physician, the AGC team will go to a patient’s home to conduct the initial assessment or discipline-specific follow-up assessments.
The AGC works in partnership with a number of community geriatric services and is part of the Algoma Geriatric Network Steering Committee. “This committee is comprised of membership from various partner organizations across the community. Our purpose is to ensure that older adults have timely access to coordinated geriatric services, designed to optimize their health and support their independence and quality of life. We are currently working on developing some online educational resources for the community,” states Luther.
The AGC is accepting new referrals which can be made through your physician or nurse practitioner. We also encourage patients and their families/caregivers reach out to our clinic for resources and information, or to visit the SAH website at www.sah.on.ca.
“We are proud of the progress we have made in our clinic and we look forward to continuing to make a positive difference in providing holistic care for geriatric patients and their families in the district of Algoma.”
Rose Calibani is the Public Affairs Officer at Sault Area Hospital. We welcome comments and suggestions for future column topics. Please call Public Affairs at (705) 759-3671.